The present invention relates to a method and apparatus for reducing signal noise in a fetal ECG signal, typically one obtained by using a unipolar ECG lead configuration which detects a predominant T wave vector whilst avoiding changes in ECG waveform shape due to fetal rotation through the birth canal.
Fetal surveillance during labour is standard clinical practice. The purpose is to identify abnormal events and fetal oxygen deficiency in particular. Since its introduction in the sixties it has been evident that electronic fetal monitoring by fetal heart rate analysis alone does not provide all the information required for an optimal identification of a fetus suffering from lack of oxygen.
During the last 20 years work has been ongoing to clarify what fetal signals could be made use of to provide additional information. Since the early seventies, waveform analysis of the fetal electrocardiogram has been studied from both physiological, signal processing and clinical aspects (Rosen KG: Fetal ECG waveform analysis in labour. Fetal monitoring. Physiology and techniques of antenatal and intrapartum assessment. ad. Spencer JAD). Castle House Publications. pp. 184-187,1989). It was found that the ST interval and T-wave amplitude were of particular interest.
FIG. 1 depicts two consecutive heart beats with the different ECG components of interest during foetal surveillance being identified. It has been found that changes in the ST interval of the Fetal Electro CardioGram (ECG) are part of the components that reflect the stress of the fetal heart during the labour. Basically, the changes that appear in the ST interval due to lack of oxygen, can be divided into 3 classes:
1. ST rise with increased ST segment and T wave amplitude;
2. Appearance of so called biphasic ST changes, with an ST segment with a negative slope;
3. Appearance of negative T waves.
These discoveries have been applied in a clinical trial in which the ST-waveform (ie. the ST segment plus the T wave) of the fetal electrocardiogram was shown to provide more useful information than the mere detection of RR-intervals (fetal heart rate) (Westgate J, M Harris, J S H Curnow, R R Greene: Plymouth randomised trial of cardiotocogram only versus ST waveform plus cardiotocogram for intrapartum monitoring; 2400 cases. Am J Obstet Gynaecol 169(1993)1151).
Several problems regarding the fetal ECG-signal quality have been identified over the years. Clearly, it is a prerequisite to be able to detect the ST waveform, and so one of the main requirements for ST-waveform analysis of the fetal electrocardiogram is a fetal ECG lead configuration that is consistent and allows the identification of the T vector during labour.
The conventional ECG level configuration used for fetal monitoring is the bipolar fetal ECG lead configuration. Here, both exploring electrodes are located close to each other on the presenting part of the fetal body, ie. the head or buttock. As a consequence of the location of the electrodes, there is a maximum sensitivity to ECG waveform changes with a main vectorial distribution in the horizontal plane of the fetus. However, experimental data have shown a maximal representation of T wave vector along the longitudinal axis of the fetus. Thus, the standard fetal ECG lead, well suited when only using the R wave for fetal heart rate detection, will not enable the accurate detection of changes in T wave amplitude.
This can only be done by constructing an ECG lead that is sensitive to ECG waveform changes appearing in the longitudinal axis of the fetus. It is known from the literature that the use of a unipolar fetal ECG lead configuration enables the detection of the main T-wave vector more accurately then the standard bipolar ECG lead configuration (Lindecrantz K, Lilja H, Widmark C, Rosen KG: The fetal ECG during labour. A suggested standard. J. Biomed. Eng. 1988; 10: 351-353). In this configuration, one of the exploring electrodes is located well away from the fetus, e.g. on the maternal skin. The maternal thigh has been found to be a suitable place. The other exploring electrode is the standard scalp electrode needle placed under the skin of the presenting fetal part.
A further problem is the existence of signal noise which is far more significant when the S-T waveform is being studied than is the case with conventional fetal ECG monitoring. An illustration of progressive changes in the ST segment of the foetal ECG recorded during labour is presented in FIGS. 2a-c. The ECG baseline as indicated by the present invention is depicted as well. The appearance of biphasic changes in the ST segment follows a pattern, which is exemplified in FIGS. 2a-c. This is a sequential recording showing 30-beat ECG averages. As seen in FIGS. 2a-c, the ST segments are classified in a 3-level scale that reflects the relation between the negative slope of the ST segment compared to the baseline of the ECG. As will be appreciated, to be able to perform this type of analysis, a very high signal quality regarding low frequency noise is required.
Although the unipolar fetal ECG electrode configuration discussed above enables the T vector to be identified, a signal noise problem is generated at the same time. The maternal skin electrode is sensitive to maternal movements causing both low frequency (movement artifacts) and high frequency (muscular activity) noise. Another source of noise is the interference from mains frequencies.
Thus, the sources of signal noise may be summarised as:
A. High frequency components related to muscle activity.
B. Interference from mains frequencies.
C. Low frequency noise largely generated by fetal and maternal movements
Any system for assessment of the ST-waveform of the fetal electrocardiogram has to reduce the interference from these potential sources of signal noise, but obviously, any techniques applied to reduce signal noise should not significantly interfere with the ST waveform. Furthermore, the signal processing should be done continuously as the state of oxygen delivery to the fetus can change from one minute to another and any delay in the presentation of ECG-waveform data would be disadvantageous.
The technique used in the Plymouth trial (westgate et al, 1993) used analogue filtering signal processing undoubtedly with some success. However, there were limitations to what can be achieved. The fetal scalp ECG signal amplitude (QRS complex) varies normally between 100 and 400 xcexcV but the T wave is normally only {fraction (1/10)} of an amplitude of the peak signal and so great care has to be taken not to interfere with this low amplitude part of the signal. The use of analogue high pass filters to reduce low frequency (ie. below 1 Hz) baseline shifts carries the risk of markedly affecting the T wave amplitude and guidelines instituted by the American Heart Association recommend a low frequency cut-off of only 0.05 Hz (Electrocardiography recommendations for the standardization of leads and of specifications for instruments in ECG/VCG circulation. American Heart Association Committee, 1975, Pp 1-25). These guidelines were followed in the Plymouth trial.
As a consequence, the prior art analogue filtering techniques will, to only a very limited extent reduce low frequency noise generated by electrode movements and the data interpretation has therefore been limited to more robust changes. There is therefore a need to improve the quality of the fetal electrocardiogram to enable continuous and detailed assessment of ST-waveform changes during labour.
According to the present invention there is provided a method of reducing noise in a fetal ECG signal comprising connecting electrodes to the fetus and the maternal skin in a unipolar configuration and feeding the signal detected by said electrodes through a first high pass filter, the cut-off frequency of the first high pass filter being between 0.2 and 2.7 Hz.
The invention also provides an apparatus for obtaining a fetal ECG signal comprising exploring electrodes for connection to the fetus and the maternal skin in a unipolar configuration in order to detect an ECG signal and a signal noise reducing device linked to the electrodes by means of a first signalling link, wherein the signal noise reducing device comprises a first high pass filter, the cut-off frequency of the first filter being between 0.2 and 2.7 Hz.
Typically, one electrode is attached to the fetal scalp and one is attached to the maternal thigh.
The xe2x80x9ccut-off frequencyxe2x80x9d as used herein refers to the frequency below which a significant degree of signal attenuation e.g. xe2x88x923 dB, takes place. In preferred forms of the invention there may be as little as 0.1 dB attenuation in most of the pass band and around 40 dB attenuation in most of the stop band.
Thus, it will be seen that the invention provides signal filtering using a far higher cut-off frequency than that thought possible in the prior art. This is based upon a recognition that, although the baseline fluctuations of the ECG signal (due to movements, breathing, impedance variations etc.) can have a significantly higher amplitude than the ST waveform, most of the energy of the baseline fluctuation is at a lower frequency range than the frequency range of the ST interval. This is illustrated in the spectrum shown in FIG. 3. Thus, the invention provides a signal quality enhancement model that allows the accurate presentation of ECG waveform changes within the ST interval frequency.
The signal may be fed directly from the electrodes to the noise reducing device of the invention, or it may be pre-filtered, e.g. using the prior art apparatus discussed above such as an analogue band pass filter having cut-off frequencies of about 0.05 and 100 Hz. The former cut-off serves to eliminate DC levels and very low frequency components that might otherwise decrease the dynamic range of the signal.
In the device of the invention, a cut-off frequency of up to 2.7 Hz has been found satisfactory in that the T/QRS ratio is largely unaffected when the fetal heart rate is over 100 beats/min. However, in order to provide satisfactory performance with lower heart rates, it is preferred that the cut-off frequency is less than 1.7 Hz. To optimise noise reduction, the cut off frequency is preferably greater than 0.7 Hz and around 1.2 Hz is believed to be the most effective cut-off frequency overall.
The first high pass filter may be an analogue filter, but it is highly desirable that this filter should add the minimum of phase distortion and so it is believed that this invention may more readily be achieved using digital techniques, in which case the signal is digitised before being passed through the first high pass filter.
As discussed above, another source of signal noise is interference from mains frequencies. In order to decrease the influence of mains, the device preferably also comprises a notch mains frequency filter for attenuating the mains frequency contents of the ECG signal, the notch mains frequency filter preferably being applied to the ECG signal in connection with the first high pass filter. The notch mains frequency filter is arranged to correspond to the local mains frequency, for example 50 Hz or at 60 Hz. Since modern digital filters may improve signal/noise ratio substantially without causing unwanted changes in signal waveform a multitude of digital filters may be used with very narrow cut-offs to reduce interference from both low and high frequencies as well as mains noise.
The noise reducing steps described above may be combined with further steps. For example, one technique for performing noise reduction of a repetitive signal is to use averaging with equal or weighted coefficients. However, there are limitations and as an example, ECG complexes with marked baseline shift may corrupt the averaged complex causing erroneous information to be generated. It would therefore be advantageous if as much as possible of signal noise could be eliminated prior to such signal averaging.
Even modern digital (in this case high-pass) filters, may leave a part of the low frequency noise in the signal which, during an R-R interval, can be seen as a baseline shift or slope. This deviation in the available signal, compared to the real ECG, may in some circumstances make a qualified analysis of the ST segment difficult. Therefore, the invention preferably also includes a step in which residual low frequency noise of the continuous ECG signal is attenuated further using vector subtraction principles. An advantage with such a filter is the ability to operate immediately after a possible loss of signal with the ECG signal exceeding the dynamic range.
Thus, preferably a second high pass filter is provided for further attenuation of signal noise in a digitised fetal ECG signal where the signal noise is primarily constituted by baseline fluctuations of the ECG signal. The ECG signal typically comprises a sequence of ECG complexes in the form of uncompensated samples, each ECG complex including a QRS complex, the second high pass filter being arranged after the cutoff frequency high pass filter, the additional high pass filter comprising: means for identifying ECG complexes of the ECG signal and their P-Q points; means for obtaining an approximating function to a curve between one P-Q point and a proceeding or a succeeding P-Q points by using a number of proceeding and succeeding P-Q points, the number being at least one; and means for forming the compensated samples to an output signal.
One way of implementing the vector subtraction is that the means for obtaining an approximating function to the curve is arranged for determination of slopes of lines between P-Q points and proceeding or succeeding P-Q points; and compensated values y[i] are obtained according to: y[i]=x[i]xe2x88x92mxe2x88x92k(ixe2x88x92ipq), where i, x[i], m, k and ipq denote index for each sample, uncompensated sample with index i, the level of the P-Q point for the present complex, the slope for the present complex, the index for the P-Q point sample, respectively.
In case a first degree polynomial is not sufficient, it is possible that the means for obtaining an approximating function to the curve is arranged for determination of polynomials of higher degree than one, the polynomials being based on a P-Q point and proceeding and/or succeeding P-Q points.
In some circumstances, it may be possible to provide a signal of such quality that signal averaging would be unnecessary. However, when this is not the case, it may be advantageous if the device also comprises an averaging filter which is preferably applied to the ECG signal in connection with the second high pass filter. Preferably averaging takes place over twenty to thirty cycles. A larger number risks causing appreciable attenuation to the height of the T wave.